Physician marriage survey reveals sex and specialty differences in marital satisfaction factors

Physician marriage is a valuable indicator of how vocational factors (e.g. work hours, stressors) impact satisfaction in relationships and physician wellness overall. Previous studies suggest that gender and specialty influence marriage satisfaction for physicians, though these often come from limited, local, cohorts. A cross-sectional survey was designed and distributed to publicly available email addresses representing academic and private practice physician organizations across the United States, receiving 321 responses (253 complete). Responses included data on demographics, medical specialty, age at marriage, stage of training at marriage, number of children, and factors leading to marital satisfaction/distress. A multivariable ordinal logistic regression was conducted to find associations between survey variables and marriage satisfaction. Survey results indicated that 86.5% of physicians have been married (average age at first marriage was 27.8 years old), and the rate of first marriages ending is at least 14.7%. Men had significantly more children than women. Physicians married at least once averaged 1.98 children. “Other” specialty physicians had significantly more children on average than psychiatrists. Marrying before medical school predicted practicing in private practice settings. Job stress, work hours, children, and sex were most frequently sources of marital distress, while strong communication, finances, and children were most frequently sources of marital stability. Sex differences were also found in distressing and stabilizing marital factors: Female physicians were more likely to cite their spouse’s work hours and job stress as sources of marital distress. Finally, surgery specialty and Judaism were associated with higher marriage satisfaction, whereas possession of an M.D. degree was associated with lower marriage satisfaction. This study elucidated new perspectives on physician marriage and families based on specialty, practice setting, and stage of training at marriage. Future studies may focus on factors mediating specialty and sex’s impact on having children and marriage satisfaction. To our knowledge, this study is the first physician marriage survey which integrates multiple factors in the analysis of physician marriages.


Survey distribution
A cross-sectional survey was designed using Qualtrics XM software [Version February, 2023: https:// www.qualt rics.com] and distributed to 2298 email addresses from publicly available internet sources representing academic and private medical centers (e.g.university hospital faculty listings, private clinic care team webpages) from across the United States.For example, a list of medical schools by state was procured, and relevant contact points for each medical school (e.g. research coordinator, public relations chairperson, communications) were added to the email list.For smaller, private physician groups, administrative or executive staff were often contacted.As a result, response rate and bias was likely complicated depending on dissemination (or lack thereof) within a given organization.

Survey design
The survey collected data about each physician's medical degree (e.g.M.D., D.O., M.B.B.S.), additional degrees, level of practice, practice setting (i.e.academic or private), medical specialty, marital status, number of marriages/ divorces, stage of training (e.g.residency, attending, retired) along with demographic information including physician's state of practice, race, religion, and year of birth.
For physicians that have been married, marriage year, stage of training at marriage, specialty of spouse (if physician), number of children, satisfaction, sources of stress, sources of stability, divorce or separation status, and year of divorce or separation (if applicable) for each marriage were collected.From this information, age at marriage and length of marriage were calculated, where applicable.
These questions were included in the survey for a variety of reasons, often in response to the previous (albeit limited) literature on physician marriage and satisfaction.For example, specialty choice was included since it was a central focus of the seminal Johns Hopkins study on physician divorce 11 .The emphasis on gender, children, and factors leading to stability or dissatisfaction in marriage were similarly motivated by previous studies 5,6,9,16 .Other variables, like practice setting and stage of training at marriage, were included because they were not well-represented in previous literature on physician marriage.
Thus, the survey was designed to contribute to a fuller understanding of factors previously investigated in physician marriage and satisfaction (by attempting to replicate earlier findings) while also providing new perspectives on some variables underexplored thus far (e.g.practice setting and stage of training at marriage).

Responses and exclusion criteria
The survey was active through January and February 2023, during which 321 responses were collected (253 complete and included), resulting in a 14.0% response rate.This response rate may be inaccurate insofar as recipients may have forwarded the survey within their institutions and some recipient email addresses may have no longer been actively monitored at the time of survey distribution.Responses were excluded if the respondent
The chi-square and ANOVA tests were applied using independent variables like age, specialty, current level of practice, and gender compared to dependent variables like number of children and satisfaction in marriage ("Yes" or "No").Factors like practice setting (i.e.academic or private) served as independent or dependent variables according to which association was under investigation (e.g.practice setting could be an independent variable for satisfaction in marriage and a dependent variable with respect to specialty).If chi-squared analysis on nominal variables was significant, pairwise chi-squared analysis with Holm-Sidak correction was done to determine which categories had significant differences.

Multivariable analysis
We conducted a multivariable regression, considering survey items that received over 150 responses.Only responses encompassing all considered variables were retained for further examination.To facilitate analysis, variable aggregation was performed (e.g.adding the number of children across marriages to arrive upon the total number of children per physician).Additionally, variables for which all responses were the same were filtered out, since these variables would not, by themselves, contribute to the resulting analysis.For nominal variables, we adopted a one-hot encoding strategy.To address the issue of perfect separation resulting in singular matrices due to one-hot encoding, we excluded the category with the fewest participants for each nominal variable from the analysis.Binary variables were represented as [0, 1], while ordinal variables were encoded as integers maintaining temporal coherence (e.g. for the current level of practice, "resident" preceded "fellow").Marriage satisfaction was used as the dependent variable and was also encoded ordinally, reflecting increasing satisfaction levels (i.e.not satisfied, somewhat satisfied, satisfied).Ratio data, being inherently numerical, underwent no additional encoding.
To mitigate high collinearity, we calculated the variance inflation factor (VIF) for each candidate feature.Features with the highest VIF were iteratively dropped from the analysis to account for systemic multicollinearity changes if its VIF exceeded the standard threshold of 5.
For modeling, we used an ordinal logistic regression (All-threshold variant) to determine feature coefficients.To enhance model robustness and prevent overfitting, we applied ridge regularization with α = 0.01.Coefficient significance was assessed using the Wald test (α = 0.05).

Demographic information
See Table 1 for full demographic data.Of the completed and included survey submissions, 57.4% of respondents (144) identified as female.Respondents spanned 34 United States/territories and were 76.3% white (193), with Asian (9.5%, 24) and Black (6.3%, 16) composed the next most represented races.Hispanic or Latino physicians made up 8.8% of respondents.

Education
All participants possessed a medical degree: 212 (83.8%) had a Doctor of Medicine degree (M.D.), 39 (15.4%) had a Doctor of Osteopathic degree (D.O.), and 2 (0.8%) had a Bachelor of Medicine, Bachelor of Surgery degree (M.B.B.S.).Less than a quarter (22.2%) of respondents had an additional degree, like a Doctor of Philosophy (Ph.D.) or Master's degree.

Practice information
The respondents occupied a spectrum of the medical training pathway: 38 (15.1%) were resident physicians, 4 (1.6%) were fellows, 193 (76.9%) were attending physicians, and 16 (6.4%)were retired.Just under two-thirds (64.7%) of respondents practiced in an academic setting, while the remaining third (35.3%) were in a private practice setting.

Marriage and relationships
Of 252 respondents to questions about marriage, 218 (86.5%) were either currently married or previously married.The average age of a physician at their first marriage was 27. 8  www.nature.com/scientificreports/composed 207 (82.1%) of total respondents.One quarter of currently married physicians were married to another physician (26.1%).Dual physician marriages were not significantly more or less likely to end in divorce than other physician marriages.Over half (56.8%) of currently unmarried physicians were in a romantic relationship.Survey results showed that 14.7% of ever-married physicians have at least once been in a marriage that has ended, and 11.2% have been married more than once.Of first marriages that ended, 87.5% (28 of 32) ended in divorce and the remaining 12.5% (4 of 32) ended in the death of the spouse.See Fig. 1 for a visual overview of the marital characteristics of respondents.

Children
See Fig. 2 for a summary of specialty choice's association with the number of children physicians have.On average, physicians married at least once had around two children (1.98) overall.In addition to the aforementioned associations involving children (private practice physicians were more likely to have children and had more children on average than academic physicians, "other" specialty physicians were more likely to have children and had more children on average than psychiatrists), several more associations involving children were found.
For example, physicians who identified themselves as male had more children, on average, than physicians who identified themselves as female, both in total (p < 0.001, F = 12.2) and in the current marriage (p = 0.006, F = 7.6).The stage of training in which a physician married influenced the number of children they had from that marriage (p = 0.002, F = 5.0).Physicians married before medical school had the most children (μ = 2.79, n = 34), physicians married during residency had the next most children (μ = 1.93, n = 54), then physicians married during medical school (μ = 1.64, n = 61), and finally physicians married as an attending (μ = 1.61, n = 41).This pattern closely follows, but does not match, ascending average age per stage of training (which, youngest to oldest, was before medical school, during medical school, during residency, and as an attending).www.nature.com/scientificreports/

Specialty
No significance was found in specialty choice's influence on marriage satisfaction, number of children, or likelihood of divorce.While the family medicine and psychiatry specialties each reported the highest number of divorces (6 each, 10.5% of family medicine physicians and 16.2% of psychiatrists), no statistically significant correlations between specialty choice and marriage outcome were found.Similarly, no significant differences between specialty choice and whether a physician is satisfied with their marriage was found.Specialty choice did not appear to correlate with the stage of training at which a physician got married.www.nature.com/scientificreports/However, physicians in the "other" specialty (e.g.neurology, anesthesia, dermatology) category had a significantly higher average number of children than psychiatrists across all marriages (p = 0.02, F = 5.4) and current marriage (p = 0.04, F = 4.4).These "other" specialty physicians were also significantly more likely to have children from their current marriage than psychiatrists (p = 0.02, χ 2 = 11.5)No such associations were found between any other pair of specialties.

Practice setting
Practice setting (private versus academic) was not associated with more marriages or divorces.However, practice setting was found to be associated with the average number of children physicians have, with private practice physicians having significantly more children on average than academic physicians (p < 0.001, F = 46.6)and more likely to have children from their current marriage (p = 0.02, χ 2 = 11.4) than academic physicians.The stage of training in which a physician married (e.g.before medical school, during residency, etc.) varied significantly with the practice setting (private or academic) of the physician (p = 0.03, χ 2 = 19.7).Physicians married during residency were significantly more likely to practice in an academic setting than physicians married before medical school (p = 0.01, χ 2 = 12.8).See Fig. 3.
The most common sources of stress that physicians named for their marriage were stress from their job (67.4%), their work hours (62.7%), children (39.9%), and sex (36.27%).The most common sources of marriage stability were strong communication (70.9%), finances (62.8%), and children (57.7%).See Fig. 4 for a summary of the distressing and stabilizing factors recorded in the survey.
Distressing and stabilizing factors were also analyzed as a function of sex and specialty (see Figs. 5 and 6).Female physicians were significantly more likely than male physicians to select their spouse's work hours (p = 0.02, χ 2 = 5.7) and stress from their spouse's job (p = 0.04, χ 2 = 4.1) as sources of marital distress.Conversely, male physicians were significantly more likely to select other family members (p = 0.03, χ 2 = 4.7) and their work hours (p = 0.01, χ 2 = 6.7) as sources of marital stability.However, female physicians were significantly more likely to select their spouse's work hours as a source of marital stability (p = 0.03, χ 2 = 4.5).
Significant differences in findings for stabilizing and distressing factors between specialties were not found, with one exception.Surgeons were significantly more likely than psychiatrists to select children as a source of marital stability (p = 0.02, χ 2 = 9.2).

Multivariable analysis
See Fig. 7 for a visualization of the ordinal logistic regression.We identified 15 dependent variables for inclusion in our multivariable analysis.From the dataset, 179 responses addressed all dependent variables and were consequently incorporated into the analysis.Subsequent to variable encoding and exclusion based on variance inflation factor thresholding, a total of 52 features were retained for the ordinal logistic regression.
Among these features, four exhibited statistical significance: possessing an M.D. degree (coefficient = − 5.64, p < 0.00001), specializing in surgery (coefficient = 3.89, p = 0.01), and affiliating with Judaism (coefficient = 4.69, p = 0.01) or an unreported/other religion (coefficient = 4.21, p = 0.03).Positive coefficients indicate positive contributors to marriage satisfaction, while negative coefficients indicate negative contributions to marriage satisfaction.For example, the results suggest that specializing in surgery is positively associated with high marriage satisfaction, whereas possessing an M.D. degree (i.e.rather than a D.O. or M.B.B.S. degree) is negatively associated with high marriage satisfaction (i.e.M.D. degree is associated with lower marriage satisfaction).

Discussion
The wide range of findings from this survey helps contextualize other findings in the literature while adding new perspectives to satisfaction, specialty, sex, practice setting, and stage of training at marriage, and children on one another.The rate of a physician marriage ending found in this study (11.2%) is lower than the rate of divorce of the general population and other professions, which some studies have corroborated 18 .Factors leading to this increased stability may include older age at marriage and higher socioeconomic status 19 .

Children
The effect of sex on having children was also impactful for understanding physician wellness.The finding that male physicians had significantly more children on average than female physicians and were significantly more likely to have children than their female counterparts may highlight a disproportionate burden on women in child-rearing than on men.Role conflict (mediated by work hours) has been suggested to mediate marital and parental satisfaction in physicians, so the additional difficulty for women physicians to have children is an important opportunity to evaluate the structural factors (e.g.paid time off, potential career obstacles from taking sufficient time off, childcare availability) hindering a critical facet of physician wellness for women 5 .In concert with previously explored associations between having children and factors involved in physician marriage satisfaction (e.g.fewer work hours), our findings suggest that male physicians, physicians in private practice, and physicians in "other" specialties may disproportionately benefit from having children as contributors to marital stability 14,16 .By contrast, other factors involved with child-rearing, including lower earnings and strain from conflict between professional and personal responsibilities, may also impact the identified groups, though these factors for distress often fall on female physicians 15,17 .

Specialty
Strikingly, the specialty-focused findings of this study contrast with findings in a study of Johns Hopkins graduates which suggested that the rate of divorce for psychiatrists was 50% (our study estimates 16.2%) and 33% for surgeons (our study estimates 4.5%) 11 .
Additionally, no statistically significant differences between specialties and the rate of divorce were found in the present study.Deviations from the earlier study may be a consequence of confounding factors (e.g.social

Conclusion
This survey sought to characterize properties of physician marriages, including specialty choice, children, and factors leading to marital distress and stability.The study identified that specialty choice, male sex, and private practice setting is associated with having more children on average, which was often identified as a source of stability in physician marriages.Further, job stress and work hours were most frequently identified as sources of distress in physician marriages, whereas strong communication and finances were most frequently identified as sources of stability in physician marriages.Jointly, these findings strengthen the understanding of married physicians, highlighting the attributes of physicians associated with distress and stability in familial life.

Figure 1 .
Figure1.Overview of respondents' marital characteristics.Visualization of distribution of currently married, ever married, never married, and not currently married respondents.Physicians are 27.8 years old on average at their first marriage and 26.1% are currently married to another physician.One out of nine physicians evermarried physicians have been married multiple times, and seven out of eight ended first marriages were a result of divorce, rather than death of the spouse.Over half of unmarried physicians are in romantic relationships.

Figure 2 .
Figure 2. Specialty and average total number of children physicians had across all marriages."Other" specialty physicians were found to have more children, on average, than psychiatry specialization physicians.

Figure 3 .
Figure 3. Practice setting with respect to stage of training at marriage.Physicians married before medical school were significantly more likely to practice in a private practice setting compared to physicians married during medical school or residency, who were more likely to practice in an academic setting (p = .03,χ 2 = 19.7).

Figure 4 .
Figure 4. Factors contributing to marital distress (a) and marital stabilization (b).In descending percentage of respondents, stress from the physician's job, the physician's work hours, children, and sex were the most selected distressing factors for marriage.Strong communication, finances, children, and the spouse's work hours were the most selected stabilizing factors for marriage.Respondents could select multiple options for each question.

Table 1 .
Demographic and practice data for respondents.Number of respondents for survey questions and distribution of responses.